How to map and ablate left ventricular summit arrhythmias

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Date of download: 6/27/2016 Copyright © The American College of Cardiology. All rights reserved. From: Repetitive monomorphic ventricular tachycardia originating.

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Presentation transcript:

How to map and ablate left ventricular summit arrhythmias Andres Enriquez, MD, Federico Malavassi, MD, Luis C. Saenz, MD, Gregory Supple, MD, FHRS, Pasquale Santangeli, MD, Francis E. Marchlinski, MD, FHRS, Fermin C. Garcia, MD Heart Rhythm Volume 14, Issue 1, Pages 141-148 (January 2017) DOI: 10.1016/j.hrthm.2016.09.018 Copyright © 2017 Heart Rhythm Society Terms and Conditions

Figure 1 A: Anatomy of the LVS, bounded by the bifurcation of the LMCA and divided by the great cardiac vein (dotted line) into accessible and inaccessible areas. B: Long-axis section of LV. Attention is directed to the most superior portion of the left ventricular outflow tract (magnification). The LVS would be the epicardial aspect of this segment of muscular LV. The border of the LV ostium is in direct contact with the insertion of the aorta and as such the left coronary sinus of Valsalva. Below the LCC, the endocardial LV represents the opposite aspect of the epicardial LVS. The septal branches of the LAD traverse this muscle. C: Right ventricular outflow tract in its septal aspect and its proximity to the septal LV and LVS. AMC = aorto–mitral continuity; AoV = aortic valve; CS = coronary sinus; Dg = diagonal; FO = foramen vale; LAA = left atrial appendage; LAD = left anterior descending; LCC = left coronary cusp; LCX = left circumflex; LMCA = left main coronary artery; LV = left ventricle; LVS = left ventricular summit; MV = mitral valve; NCC = noncoronary cusp; PV = pulmonic valve; TV = tricuspid valve. (Reproduced with permission from McAlpine, Heart and Coronary Arteries, Springer-Verlag, Berlin - Heidelberg, 1975; Courtesy Dr. K. Shivkumar). Heart Rhythm 2017 14, 141-148DOI: (10.1016/j.hrthm.2016.09.018) Copyright © 2017 Heart Rhythm Society Terms and Conditions

Figure 2 Left ventricular summit premature ventricular complex (PVC). Earliest activation is recorded in the anterior interventricular vein (AIV) (left panel) and ablation is not limited by coronary anatomy (right panel). Radiofrequency (RF) delivery within the AIV eliminated the PVC. As a general rule, RF ablation should be avoided within 5 mm of a coronary artery visualized in at least 2 fluoroscopic projections. LAO = left anterior oblique; RAO = right anterior oblique. Heart Rhythm 2017 14, 141-148DOI: (10.1016/j.hrthm.2016.09.018) Copyright © 2017 Heart Rhythm Society Terms and Conditions

Figure 3 Successful ablation of left ventricular summit (LVS) premature ventricular complex (PVC) from the basal left ventricular endocardium. Earliest activation was recorded at a unipolar wire (arrowhead) advanced into a septal venous perforator (earlier than great cardiac vein/anterior interventricular vein and any endocardial site), suggesting an intramural origin. The ablation catheter was positioned at the left ventricular endocardium, opposite to the site of earliest activation, and radiofrequency delivery successfully eliminated the PVC. Panel A shows the initial CS venogram. In panels B and C we see the position of the catheters in right anterior oblique and left anterior oblique fluoroscopic views, respectively. Panel D shows the CARTO 3-D reconstruction with the the ablation catheter and lesion set. Panel E shows the electrograms recorded from the unipolar wire and the ablation catheter, and panel F shows the pacemap obtained by pacing from the unipolar wire. Heart Rhythm 2017 14, 141-148DOI: (10.1016/j.hrthm.2016.09.018) Copyright © 2017 Heart Rhythm Society Terms and Conditions

Figure 4 Successful ablation of left ventricular summit premature ventricular complex (PVC) from the right ventricular outflow tract (RVOT). A: Three-dimensional anatomic representation of the right ventricle, left ventricle, and venous system with the ablation catheter positioned at the anterior interventricular vein (AIV). B: Intracardiac echocardiography (ICE) catheter “fan” from the RVOT images through the tip of the catheter. The ICE view shows the green location marker for the catheter location. The earliest bipolar and unipolar activation time (–35 ms) was obtained here. C, D: Right anterior oblique and left anterior oblique fluoroscopic views showing an ablation catheter in the AIV and another ablation catheter in the RVOT (note the close proximity of both structures). Earliest activation during PVC was recorded in the AIV; however, coronary angiography revealed immediate proximity to the left anterior descending coronary artery, preventing radiofrequency application. Ablation in the RVOT (closest neighbor structure) eliminated the PVC within 4 seconds, despite a later activation and a poor pace-map. LVOT = left ventricular outflow tract. Heart Rhythm 2017 14, 141-148DOI: (10.1016/j.hrthm.2016.09.018) Copyright © 2017 Heart Rhythm Society Terms and Conditions

Figure 5 Successful ablation of left ventricular summit premature ventricular complex from the LCC. Activation at the LCC was slightly earlier than the AIV (40 ms pre-QRS). On fluoroscopy, the LCC is located at the most leftward aspect of the aortic root in the left anterior oblique view (top, right) and mid-position in the right anterior oblique view (top, left). Intracardiac recording at the LCC shows a large ventricular electrogram and a small far-field atrial electrogram. Note the close proximity between the catheter tip and the decapolar catheter placed at the AIV. AIV = anterior interventricular vein; GCV = great cardiac vein; LCC = left coronary cusp. Heart Rhythm 2017 14, 141-148DOI: (10.1016/j.hrthm.2016.09.018) Copyright © 2017 Heart Rhythm Society Terms and Conditions